What are the signs and symptoms of a Deep Vein Thrombosis (DVT)?

Signs and Symptoms of Deep Vein Thrombosis

The most common signs and symptoms of DVT include unilateral leg swelling (present in 80% of cases), pain (75% of cases), warmth, erythema (26% of cases), and tenderness in the affected extremity, though approximately one-third of patients remain completely asymptomatic. 1, 2

Primary Clinical Manifestations

Most Common Presentations

• Unilateral swelling or edema of the affected extremity is the most frequent sign, occurring in 80% of patients 2
• Pain and tenderness in the affected limb, present in 75% of cases, often described as deep tension, heaviness, or a feeling of dead weight 1, 2, 3
• Erythema or redness of the skin over the affected area, seen in 26% of patients 1, 2
• Warmth of the skin overlying the thrombosed vein 1, 4
• Dilated superficial veins (collateral circulation) may be visible 1, 4

Pain Characteristics

• Pain typically worsens with prolonged standing or walking and improves with rest or limb elevation 1, 4
• May manifest as dull cramping or an "undefinable" heavy leg sensation 3
• Can affect the calf, sole of the foot, heel, thigh, groin, or pelvis 3
• Tenderness on palpation of venous tracts is highly suggestive 3

Advanced or Severe Presentations

Severe DVT Manifestations

• Venous claudication (bursting leg pain during exercise) indicates iliofemoral or popliteal vein thrombosis 1, 4
• Phlegmasia cerulea dolens presents with severe or "intolerable" pain in Scarpa's triangle, rapidly spreading throughout the limb 3

Chronic Sequelae (Post-Thrombotic Syndrome)

• Persistent edema 1, 4
• Hyperpigmentation of the skin 1, 4
• Lipodermatosclerosis 1, 4
• Venous ulceration in severe cases 1, 4

Critical Clinical Considerations

Asymptomatic Presentations

• Approximately one-third of DVT patients have no symptoms, making clinical diagnosis extremely challenging 1, 4, 2
• Relying solely on clinical signs can lead to missed diagnoses and unnecessary anticoagulation in others 4

Location-Specific Features

• Above-the-knee (proximal) DVT is strongly associated with increased pulmonary embolism risk and requires immediate attention 1, 4
• Infrapopliteal calf vein DVT may present with milder symptoms but can extend proximally in approximately one-sixth of cases 1, 4
• Isolated iliac vein thrombosis may present with extensive unexplained leg swelling accompanied by flank, buttock, or back pain 4

Upper Extremity DVT

• Pain, erythema, and tenderness involving a superficial vein in the arm 4
• Often associated with central venous catheters or PICC lines 4

Pediatric Considerations

• CVC malfunction (inability to draw or infuse, or requirement of tissue plasminogen activator for catheter patency) should be considered a clinical sign of CVC-related DVT 5
• Clinicians should evaluate for signs/symptoms within the prior 2 weeks or longer based on chronicity 5

Warning Signs of Pulmonary Embolism

Patients with DVT should be monitored for PE symptoms, including:

• Shortness of breath and tachypnea 4
• Pleuritic chest pain 4
• Hypoxia and hemoptysis 4
• Tachycardia and syncope 4

Common Pitfalls and Mimics

Conditions That Mimic DVT

• Baker's cyst 1, 4
• Cellulitis 1, 4
• Lymphedema 1, 4
• Chronic venous disease 1, 4
• Musculoskeletal disorders 1, 4

Important Caveats

• Superficial vein thrombosis can occur simultaneously with DVT and predisposes patients to deep system involvement 1, 4
• Extensive superficial vein thrombosis in the saphenous vein can progress to involve the deep venous system at the saphenofemoral junction, potentially leading to pulmonary embolism 1
• Maintain high clinical suspicion even in the absence of classic symptoms 2

Diagnostic Approach

Do not rely on clinical assessment alone—proceed with objective testing:

• Use compression ultrasonography as the initial diagnostic test 4, 2, 6
• Consider early anticoagulation while awaiting imaging if high clinical suspicion exists and no contraindications are present 2
• In cancer patients, proceed directly to compression ultrasonography without using clinical prediction rules or D-dimer testing 1